any interesting changes you see in psychiatry?

[randomdoc1]

Just thought it may be a fun discussion. In PP I find it interesting to see NP encroachment in TMS. Generally it's at the high traffic places that are desperately in need of hiring more people and the paucity of psychiatrists. But it's also had some nice side effects. I've had patients coming to my office, starting to appreciate the training of a physician compared to an NP. One patient mentioned that an NP really didn't seem to have a good working knowledge of TMS themselves. Another was an NP trying to do a mapping session and they couldn't figure out the parameters. I mapped the patient and admit, she was hard to map, but definitely able to be mapped.

And I don't know about other geographic locations, but Medicaid where I live is starting to pay out some baller dollars for psychologists to bill 90837. So we've opened our clinic up real wide for Medicaid cases. Which really starts to push United Healthcare way down the food chain. Hopefully someday UHC feels more and more of the pinch so they actually pay livable wages.

---

Members don't see this ad.

 

[wolfvgang22]

There is a private ketamine clinic nearby that gives I.V. ketamine and a MDD, recurrent, severe diagnosis to whoever walks in the door. It is run by a family practice NP. She charges a lot. The clinic is next to a shop that sells CBD and Kratom. It's super popular. I'm not a fan. I regularly get patients from over there seeking less expensive ketamine treatment. Most often they trialed Paxil 10mg for 2 weeks in the past from their primary care physician and quit due to GI side effects. But once they've had the KK CBD protocol that's all they want.

 

[randomdoc1]

There is a private ketamine clinic nearby that gives I.V. ketamine and a MDD, recurrent, severe diagnosis to whoever walks in the door. It is run by a family practice NP. She charges a lot. The clinic is next to a shop that sells CBD and Kratom. It's super popular. I'm not a fan. I regularly get patients from over there seeking less expensive ketamine treatment. Most often they trialed Paxil 10mg for 2 weeks in the past from their primary care physician and quit due to GI side effects. But once they've had the KK CBD protocol that's all they want.

That is pretty much the profile I've seen of many patients coming to the local ketamine clinic here, except it's run by an anesthesiologist so he looks flashier. I remember one case of borderline personality disorder, they did the IV ketamine, and patient went into a fib. Would have loved to tell the anesthesiologist "told ya so [should've just tried prozac first lolololol]".

 

[whopper]

An issue that no one has addressed in academia or professional societies is that many of the paranoid delusions based on implanted devices, EM waves, etc will no longer be stuff of sci-fi but real.

There's already been documented cases with evidence to back them up as really have happened of US diplomats possibly having been the victim of EM or sonic based weapons.

Victims of Havana embassy ‘sonic attack’ have distinctly different brains, MRIs show

Researchers found significant differences in various measures of the brains of people who were victims of the “sonic attack” at U.S. embassy in Havana.

www.latimes.com

Where will we be, say 20 years from now, when brain implants, EM weapons, etc are no longer stuff of spy novels but real and a patient believes they are the victim of such a thing? It's easy to now say they're delusional. Won't be able to do so in the future without testing to rule it out.

What I suspect is psychiatry will go through an era where several patients are misdiagnosed as having been psychotic when in fact it is Martha Mitchell Effect.

 

[Sushirolls]

LOL, So looks like we will have our overhead increased because we will need to have full MRI machines (or something similar?) to spot devices, and various labs to locate markers of devices...
I can only imagine getting insurance to reimburse for this "invasive tech screening" and naturally, it won't appear until ICD-15 update, despite having needed it at ICD-13. We'll then see a split based upon insurance company coverages for this...
Nefarious criminal elements will likely seek out those whose insurance is *cough randomdoc1's favorite insurance company* *cough* because they will be one of the last to cover it. But considering we will have universal portable health records by then - which are also easily hacked on a daily basis - said criminal gangs will easily reference these black market databases of who to target... I watch too much SciFi.

And no the psychiatric units won't have these devices screen, nor tests, because only the for profit hospitals for some reason are still in the inpatient unit business, and hey have no desire invest in tech, because, well one of them around here is still intentionally using paper notes...

LOL, but folks won't even bother to go Psychiatrists. Who am kidding? They go to Doctors of Advanced Medicine Natropathic (DAMN) who will have mobile infusion clinics that have a "natural" remedy that fries all miniscule electronics - their popularity and growth exceeds all other medical professions, and the Natropathic Doctors are furious at their success. But their failures are never known, because their 'medical board' doesn't actually do anything, but the keenly advertise how they have 0 license disciplines per year!

 

[Stagg737]

Even in my brief time within the field, it seems like the rise of CBD and changing attitudes on marijuana has made differentiating people with actual SUDs vs people just trying to get relief from anxiety, insomnia, or whatever a bit easier. I've found a large percentage of my CBD-using patients are willing to try other methods and stop CBD once other treatment are effective versus those clutching their b***s insisting their anxiety is out of control without marijuana.

LOL, but folks won't even bother to go Psychiatrists. Who am kidding? They go to Doctors of Advanced Medicine Natropathic (DAMN) who will have mobile infusion clinics that have a "natural" remedy that fries all miniscule electronics - their popularity and growth exceeds all other medical professions, and the Natropathic Doctors are furious at their success. But their failures are never known, because their 'medical board' doesn't actually do anything, but the keenly advertise how they have 0 license disciplines per year!

Why take CBD daily when you can get a tincture of it infused at 100x the price!

 

[whopper]

I also see hallucinogens becoming a MAT treatment for people with treatment resistant anxiety or depression but this could take years.

 

[wolfvgang22]

I also see hallucinogens becoming a MAT treatment for people with treatment resistant anxiety or depression but this could take years.

I have mixed thoughts about this. There is so much enthusiasm for hallucinogens, that seems to come from the same ketamine/CBD/Kratom crowd I mentioned above. I think those are not exactly sober minded individuals. Also, historically we've seen what has happened with "wonder drugs." They are nearly always overprescribed only to find that wasn't such a great idea later. Anything to avoid psychotherapy, I guess. Maybe it will help some people.

 

[Stagg737]

I have mixed thoughts about this. There is so much enthusiasm for hallucinogens, that seems to come from the same ketamine/CBD/Kratom crowd I mentioned above. I think those are not exactly sober minded individuals. Also, historically we've seen what has happened with "wonder drugs." They are nearly always overprescribed only to find that wasn't such a great idea later. Anything to avoid psychotherapy, I guess. Maybe it will help some people.

While I'm pretty enthusiastic and interested in the hallucinogen angle for TRD, the population that brings it up most frequently are not the people I'd typically want to give a trial to. I'm also interested to see data come out potentially differentiating hallucinogens for true TRD vs. more of a PDD/depressive PD picture.

 

[WisNeuro]

I have mixed thoughts about this. There is so much enthusiasm for hallucinogens, that seems to come from the same ketamine/CBD/Kratom crowd I mentioned above. I think those are not exactly sober minded individuals. Also, historically we've seen what has happened with "wonder drugs." They are nearly always overprescribed only to find that wasn't such a great idea later. Anything to avoid psychotherapy, I guess. Maybe it will help some people.

Well, I want to get better, but I just don't want to have to actually do anything to get better.

 

[Orgone]

An issue that no one has addressed in academia or professional societies is that many of the paranoid delusions based on implanted devices, EM waves, etc will no longer be stuff of sci-fi but real.

There's already been documented cases with evidence to back them up as really have happened of US diplomats possibly having been the victim of EM or sonic based weapons.

Victims of Havana embassy ‘sonic attack’ have distinctly different brains, MRIs show

Researchers found significant differences in various measures of the brains of people who were victims of the “sonic attack” at U.S. embassy in Havana.

www.latimes.com

Where will we be, say 20 years from now, when brain implants, EM weapons, etc are no longer stuff of spy novels but real and a patient believes they are the victim of such a thing? It's easy to now say they're delusional. Won't be able to do so in the future without testing to rule it out.

What I suspect is psychiatry will go through an era where several patients are misdiagnosed as having been psychotic when in fact it is Martha Mitchell Effect.

That's wild stuff. Those patient's requesting imaging, we might have to actually start doing it.

And we've already passed the point where what would have sounded like delusions of being monitored are now in fact reality. It turns out that now, yes sir, there are in fact cameras watching you everywhere you go. Have a cell phone? Ok great, your location is being tracked too.

There's another issue that's come up for me several times in the last couple of years with the societal focus on improper policing and prosecution. I've had a few cases where it's been very difficult to draw the line between delusional beliefs about legal system persecution, versus "overvalued beliefs" that are these days fairly mainstream in some populations.

 

[randomdoc1]

Well, I want to get better, but I just don't want to have to actually do anything to get better.

Apparently you clearly have not heard of the highly efficacious Adderal IR + Xanax combination. Just keeping putting uppers and downers in until you get the perfect flow of your emotions, it'll balance out eventually.

 

[whopper]

I've mentioned this in other threads. Some surgeons who implant devices are now requesting psychiatry to "clear the patient for surgery" despite that there's no solid criteria yet to clear such as person. So if I refuse the surgeon now won't do the surgery. I even asked the surgeon "what is the criteria to clear?" and the surgeon responds "I don't know. I thought you knew." So we discuss this and they tell me the device's manufacturer says it requires psych clearance.

So I call, fax and write a letter to the manufacturer requesting what the criteria is and the manufacturer either doesn't respond or gives me a "I'm just a guy who works here. I don't know what this is" response.

It's already happening now so my so called prediction is actually ongoing now.

 

[WisNeuro]

Apparently you clearly have not heard of the highly efficacious Adderal IR + Xanax combination. Just keeping putting uppers and downers in until you get the perfect flow of your emotions, it'll balance out eventually.

This is the art part of practice, right?

 

[Merovinge]

This is the art part of practice, right?

God, I really want an NFT generating procedural art that makes a collage of Xanax 2mg bars and Adderall IR 30mg tabs.

 

[WisNeuro]

God, I really want an NFT generating procedural art that makes a collage of Xanax 2mg bars and Adderall IR 30mg tabs.

Make a series with alternating contrast colors from the color wheel, sell at 10+ ETH a piece. People are spending more than that to buy this type of junk.

 

[Merovinge]

Make a series with alternating contrast colors from the color wheel, sell at 10+ ETH a piece. People are spending more than that to buy this type of junk.

Wish I knew how to do this, because I would actually buy a piece like this if it were cheap. I'm imaging each one has different ratios of Xanax to Adderall and the pills in different orientations. Then 1 of the 1000 has a distribution with the pills forming a smiley face, that one sells for 100 eth.

 

[whopper]

Apparently you clearly have not heard of the highly efficacious Adderal IR + Xanax combination. Just keeping putting uppers and downers in until you get the perfect flow of your emotions, it'll balance out eventually.

All I want in life is millions of dollars, exotic sports cars, a mansion, a swimming pool, dozens of hot women and a Michelin star chef as my personal chef. Now is that too much to ask for? Does that make me a bad person?

 

[randomdoc1]

All I want in life is millions of dollars, exotic sports cars, a mansion, a swimming pool, dozens of hot women and a Michelin star chef as my personal chef. Now is that too much to ask for? Does that make me a bad person?

Are you saying you can't give me pills to get those? wtf kind of psychiatrist are you.

 

[Merovinge]

All I want in life is millions of dollars, exotic sports cars, a mansion, a swimming pool, dozens of hot women and a Michelin star chef as my personal chef. Now is that too much to ask for? Does that make me a bad person?

I cannot imagine the misery of the hedonic adaption to that type of life. I get excited thinking about the months until my Model Y is going to get delivered, the 1-2 Michelin star meals/year and the 1-2 exotic vacations/year and that's already an extremely luxurious life.

 

[tr]

I have mixed thoughts about this. There is so much enthusiasm for hallucinogens, that seems to come from the same ketamine/CBD/Kratom crowd I mentioned above. I think those are not exactly sober minded individuals. Also, historically we've seen what has happened with "wonder drugs." They are nearly always overprescribed only to find that wasn't such a great idea later. Anything to avoid psychotherapy, I guess. Maybe it will help some people.

Really? But the effect sizes and effect durations with psilocybin and MDMA are out of this world. I don't think they compare to the ketamine literature at all, never mind whatever CBD literature exists, which seems largely negative for anxiety at least.

Also I'd like to point out that the hallucinogens/entheogens are employed specifically in pharmacologically assisted psychotherapy. As far as I am aware, all such interventions tested have had a major psychotherapy component. The hallucinogen/entheogen is synergistic with the psychotherapy, not an alternative to it. Otherwise it's not an intervention, just a recreational trip/roll.

 

[nexus73]

I've mentioned this in other threads. Some surgeons who implant devices are now requesting psychiatry to "clear the patient for surgery" despite that there's no solid criteria yet to clear such as person. So if I refuse the surgeon now won't do the surgery. I even asked the surgeon "what is the criteria to clear?" and the surgeon responds "I don't know. I thought you knew." So we discuss this and they tell me the device's manufacturer says it requires psych clearance.

So I call, fax and write a letter to the manufacturer requesting what the criteria is and the manufacturer either doesn't respond or gives me a "I'm just a guy who works here. I don't know what this is" response.

It's already happening now so my so called prediction is actually ongoing now.

What types of implants?

 

[SourceOfDenial]

I have mixed thoughts about this. There is so much enthusiasm for hallucinogens, that seems to come from the same ketamine/CBD/Kratom crowd I mentioned above. I think those are not exactly sober minded individuals. Also, historically we've seen what has happened with "wonder drugs." They are nearly always overprescribed only to find that wasn't such a great idea later. Anything to avoid psychotherapy, I guess. Maybe it will help some people.

Weird take, since psychedelics for treatment require a lot of therapy. I’d put money on the better and longer the therapy the better the outcomes.

I have run integration groups and psychedelics are finally something worth getting excited about in mental health.

 

[Stagg737]

Really? But the effect sizes and effect durations with psilocybin and MDMA are out of this world. I don't think they compare to the ketamine literature at all, never mind whatever CBD literature exists, which seems largely negative for anxiety at least.

Also I'd like to point out that the hallucinogens/entheogens are employed specifically in pharmacologically assisted psychotherapy. As far as I am aware, all such interventions tested have had a major psychotherapy component. The hallucinogen/entheogen is synergistic with the psychotherapy, not an alternative to it. Otherwise it's not an intervention, just a recreational trip/roll.

Actually some of the newer studies have looked at hallucinogens (specifically psilocybin) without adjunct psychotherapy. I remember at APA last year the below article with psilocybin showing slightly higher efficacy than lexapro was a big deal:

https://www.nejm.org/doi/full/10.1056/nejmoa2032994

 

[Mad Jack]

Apparently you clearly have not heard of the highly efficacious Adderal IR + Xanax combination. Just keeping putting uppers and downers in until you get the perfect flow of your emotions, it'll balance out eventually.

I hear they work fine if you add buprenorphine to smooth them out

 

[OpheliaButz]

Re: device implant/trial clearances
I’m a pain doc who was trained in psych prior to pain fellowship. The insurance company demands an evaluation prior to spinal cord stimulation trial ostensibly to ensure the patient isn’t totally crazy and won’t rip the multi thousand dollar leads out of her back. They are looking to ensure there are no axis I diagnoses or social issues that would prevent the patient from being able to tolerate such a device. Is it ridiculous? Yes, because most of us can tell when a patient is not a good candidate for SCS trial for these reasons and not consider it. However, an easy consult for you and there’s no liability on your part should anything go wrong with the trial or implant. BTW no I am not permitted to do my own psych evals before a trial or implant

 

[hallowmann]

Actually some of the newer studies have looked at hallucinogens (specifically psilocybin) without adjunct psychotherapy. I remember at APA last year the below article with psilocybin showing slightly higher efficacy than lexapro was a big deal:

https://www.nejm.org/doi/full/10.1056/nejmoa2032994

The thing is the trajectory of these things is always to the most basic and cheapest iteration. This gets studied with really good results when combined with very skilled and lengthy psychotherapy. People get excited that it's "the" answer, people start saying you don't even need the therapy, it's just that good! Then you have pop up clinics only doing the psychedelics, cash only, following 20 min "eval". There is already a very poor supply of skilled psychotherapy, so there is no way this is going to be implemented in the way the promising studies were. Maybe I'm being too cynical.

 

[randomdoc1]

The thing is the trajectory of these things is always to the most basic and cheapest iteration. This gets studied with really good results when combined with very skilled and lengthy psychotherapy. People get excited that it's "the" answer, people start saying you don't even need the therapy, it's just that good! Then you have pop up clinics only doing the psychedelics, cash only, following 20 min "eval". There is already a very poor supply of skilled psychotherapy, so there is no way this is going to be implemented in the way the promising studies were. Maybe I'm being too cynical.

I have definitely seen pop up clinics, not necessarily in regards to psychedelics. But ketamine for example, yes there is some literature for it in specific circumstances. But somewhere out there is a provider who will take that literature and take it way too far. And then you have, as you said, these pop up clinics with poorly conducted "evals". They ask the primary psychiatrist to sign off to cover their butts, but even when the psychiatrist won't sign, they render the treatment anyways. I seriously thought and am still in the process of thinking of reporting this anesthesiologist to the medical board for advertising his ketamine clinic by saying ketamine is the "gold standard" treatment for PTSD, MDD, bipolar disorder and more. That is simply not true, misleading, and exploitative of a vulnerable population.

Another aside on TMS. Sometimes when I'm obtaining an authorization and I'm asked to do a peer to peer review, the psychiatrist on the other end told me some interesting things he saw. There's places running like in a med spa like setting, even popping up in the malls, trying to render TMS with very little if any physician oversight. I kid you not, in the MALL! lol. I guess maybe it goes well with the massage parlors? Anyways, they tried to get authorizations and he rolled his eyes at it and of course did not grant authorizations to those settings. That's one place at least where insurance is doing some good.

 

[splik]

I have definitely seen pop up clinics, not necessarily in regards to psychedelics. But ketamine for example, yes there is some literature for it in specific circumstances. But somewhere out there is a provider who will take that literature and take it way too far. And then you have, as you said, these pop up clinics with poorly conducted "evals". They ask the primary psychiatrist to sign off to cover their butts, but even when the psychiatrist won't sign, they render the treatment anyways. I seriously thought and am still in the process of thinking of reporting this anesthesiologist to the medical board for advertising his ketamine clinic by saying ketamine is the "gold standard" treatment for PTSD, MDD, bipolar disorder and more. That is simply not true, misleading, and exploitative of a vulnerable population.

Another aside on TMS. Sometimes when I'm obtaining an authorization and I'm asked to do a peer to peer review, the psychiatrist on the other end told me some interesting things he saw. There's places running like in a med spa like setting, even popping up in the malls, trying to render TMS with very little if any physician oversight. I kid you not, in the MALL! lol. I guess maybe it goes well with the massage parlors? Anyways, they tried to get authorizations and he rolled his eyes at it and of course did not grant authorizations to those settings. That's one place at least where insurance is doing some good.

There was a psychiatrist round here drugging pts and staff with ketamine and then forcing himself sexually on them. Also doing home visits and having sex with a pts relative and prescribed her the abortion pill when she became pregnant….

 

[calvnandhobbs68]

I have definitely seen pop up clinics, not necessarily in regards to psychedelics. But ketamine for example, yes there is some literature for it in specific circumstances. But somewhere out there is a provider who will take that literature and take it way too far. And then you have, as you said, these pop up clinics with poorly conducted "evals". They ask the primary psychiatrist to sign off to cover their butts, but even when the psychiatrist won't sign, they render the treatment anyways. I seriously thought and am still in the process of thinking of reporting this anesthesiologist to the medical board for advertising his ketamine clinic by saying ketamine is the "gold standard" treatment for PTSD, MDD, bipolar disorder and more. That is simply not true, misleading, and exploitative of a vulnerable population.

Another aside on TMS. Sometimes when I'm obtaining an authorization and I'm asked to do a peer to peer review, the psychiatrist on the other end told me some interesting things he saw. There's places running like in a med spa like setting, even popping up in the malls, trying to render TMS with very little if any physician oversight. I kid you not, in the MALL! lol. I guess maybe it goes well with the massage parlors? Anyways, they tried to get authorizations and he rolled his eyes at it and of course did not grant authorizations to those settings. That's one place at least where insurance is doing some good.

Yeah IV ketamine is basically the wild west right now because it's all cash only, so very little oversight whatsoever. So you have CRNAs/anesthesiologists/etc going out there setting up IV ketamine clinics for "depression" but weirdly enough everyone who walks in the door with a few thousand bucks is depressed enough to need ketamine. I mean similar to all those other IV "therapies" they offer people on a cash only basis.

Also see TMS popping up in med-spa like settings all over the place. Haven't seen it in the mall though. But yeah, probably less able for them to do it as a "for whatever ails you approach" since most people will probably want to try to get it covered by insurance. But you definitely have those places that are like "treat your autism/insomnia/dementia/etc etc with TMS!"

 

[nexus73]

Yeah IV ketamine is basically the wild west right now because it's all cash only, so very little oversight whatsoever. So you have CRNAs/anesthesiologists/etc going out there setting up IV ketamine clinics for "depression" but weirdly enough everyone who walks in the door with a few thousand bucks is depressed enough to need ketamine. I mean similar to all those other IV "therapies" they offer people on a cash only basis.

Also see TMS popping up in med-spa like settings all over the place. Haven't seen it in the mall though. But yeah, probably less able for them to do it as a "for whatever ails you approach" since most people will probably want to try to get it covered by insurance. But you definitely have those places that are like "treat your autism/insomnia/dementia/etc etc with TMS!"

A local FM doc is doing ketamine. My patient got 6 doses between our appointments. It didn't help. The FM doc never called me, not that he knew I was seeing this patient because I don't think she told him. But how does an FM doc see a patient he's never met before and decide IV ketamine is a-ok? I doubt much lawsuit risk is involved, but it doesn't seem right to be giving IV ketamine to a patient you just met, who sought you out specifically for IV ketamine, no referral from psychiatrist. You don't know if patient has treatment resistant depression, has hx of psychosis or severe dissociation, substance use disorder. Anyone could walk in off the street with $3000 and get a round of treatments. And my patient is actually more borderline PD than anything, doing weekly DBT and me managing basic meds, so the ketamine really isn't indicated at all.

 

[Candidate2017]

Also I'd like to point out that the hallucinogens/entheogens are employed specifically in pharmacologically assisted psychotherapy. As far as I am aware, all such interventions tested have had a major psychotherapy component. The hallucinogen/entheogen is synergistic with the psychotherapy, not an alternative to it. Otherwise it's not an intervention, just a recreational trip/roll.

I'm bracing for the tidal wave of new patients with no history of depression, who can recite the full DSM-V criteria for MDD, and will claim hallucinogens are the only thing that works for their depression, but "Nah, I don't want no therapy, and BTW I have anxiety and attention issues." This will complete the holy trinity of stimulants, benzos, and hallucinogens.

 

[nexus73]

I'm bracing for the tidal wave of new patients with no history of depression, who can recite the full DSM-V criteria for MDD, and will claim hallucinogens are the only thing that works for their depression, but "Nah, I don't want no therapy, and BTW I have anxiety and attention issues." This will complete the holy trinity of stimulants, benzos, and hallucinogens.

and Suboxone

A new religion with 4 heads

The fearsome foursome

 

[Stagg737]

The thing is the trajectory of these things is always to the most basic and cheapest iteration. This gets studied with really good results when combined with very skilled and lengthy psychotherapy. People get excited that it's "the" answer, people start saying you don't even need the therapy, it's just that good! Then you have pop up clinics only doing the psychedelics, cash only, following 20 min "eval". There is already a very poor supply of skilled psychotherapy, so there is no way this is going to be implemented in the way the promising studies were. Maybe I'm being too cynical.

Just to be clear, I'm absolutely not advocating for the prescription of hallucinogens without therapy for patients and certainly not trying to suggest these should be used first line. Just that there is a bit of evidence that psychedelics on there own may have some efficacy for depression. I do think there is some promise for hallucinogens for TRD when utilized with therapy, especially if micro-dosing is shown to be an effective dose.

This will complete the holy trinity of stimulants, benzos, and hallucinogens.

and Suboxone

A new religion with 4 heads

The fearsome foursome

Lol, I always called benzos, stimulants, and opiates the unholy trinity of psych. Hallucinogens may be the perfect addition, they can be the new gospel.

 

[Merovinge]

and Suboxone

A new religion with 4 heads

The fearsome foursome

Cannot tell you how much I enjoy practicing CAP and simplifying the conversation to why we don't give non-stimulant controlled substances to children. Almost always is a positive conversation in stark contrast to the adult world.

 

[Mad Jack]

There was a psychiatrist round here drugging pts and staff with ketamine and then forcing himself sexually on them. Also doing home visits and having sex with a pts relative and prescribed her the abortion pill when she became pregnant….

That's the worst thing I think I've ever heard this side of the ice pick days

 

[Mad Jack]

The thing is the trajectory of these things is always to the most basic and cheapest iteration. This gets studied with really good results when combined with very skilled and lengthy psychotherapy. People get excited that it's "the" answer, people start saying you don't even need the therapy, it's just that good! Then you have pop up clinics only doing the psychedelics, cash only, following 20 min "eval". There is already a very poor supply of skilled psychotherapy, so there is no way this is going to be implemented in the way the promising studies were. Maybe I'm being too cynical.

Cut out the middleman and just legalize psychadelics, problem solved

 

[clausewitz2]

and Suboxone

A new religion with 4 heads

The fearsome foursome

Gotta wait for the refrain

 

[Orgone]

and Suboxone

A new religion with 4 heads

The fearsome foursome

Actually these are more likely to be the Four Horsemen of the Apocalypse.

Maybe the scientologists were right?

 

[Geraltofrivia]

Just thought it may be a fun discussion. In PP I find it interesting to see NP encroachment in TMS. Generally it's at the high traffic places that are desperately in need of hiring more people and the paucity of psychiatrists. But it's also had some nice side effects. I've had patients coming to my office, starting to appreciate the training of a physician compared to an NP. One patient mentioned that an NP really didn't seem to have a good working knowledge of TMS themselves. Another was an NP trying to do a mapping session and they couldn't figure out the parameters. I mapped the patient and admit, she was hard to map, but definitely able to be mapped.

And I don't know about other geographic locations, but Medicaid where I live is starting to pay out some baller dollars for psychologists to bill 90837. So we've opened our clinic up real wide for Medicaid cases. Which really starts to push United Healthcare way down the food chain. Hopefully someday UHC feels more and more of the pinch so they actually pay livable wages.

How do I learn about TMS and Ketamine? My program did not teach us much on this honestly

 

[birchswing]

Cannot tell you how much I enjoy practicing CAP and simplifying the conversation to why we don't give non-stimulant controlled substances to children. Almost always is a positive conversation in stark contrast to the adult world.

Is that a rule fairly widely practiced? And if so, do you know approximately when it began?

The reason I ask is that I have tried and searched to find others like me started on benzos as children and have only come across one other person but they were a bit older, even in the vast trenches of online benzo forums. It wasn't like a hail mary treatment, either. It was the first and only treatment.

My doctor was a CAP. I still have all the records.

 

[Merovinge]

Is that a rule fairly widely practiced? And if so, do you know approximately when it began?

The reason I ask is that I have tried and searched to find others like me started on benzos as children and have only come across one other person but they were a bit older, even in the vast trenches of online benzo forums. It wasn't like a hail mary treatment, either. It was the first and only treatment.

My doctor was a CAP. I still have all the records.

I do not, I have been a CAP for less than 10 years so my historical knowledge is limited. However, as a medical student in a different state this was the standard of practice. There is ample information about the risks of early substance use in the developing brain and this is often translated over as a strong theoretical concern about use of BZDs although I am not aware of good data to support this concern. Combining adolescent drinking with BZD's and diversion are also real and large concerns but again not well quantified because the practice is so rare.

This is a big reason why the longitudinal data on stimulants showing reductions in SUD and substance use generally that have been repeatedly replicated were such a big deal. Had this not been the case and rates of substance abuse increased on kids taking long-term psychostimulants, I think it would be a pretty different landscape with their use.

 

[birchswing]

I do not, I have been a CAP for less than 10 years so my historical knowledge is limited. However, as a medical student in a different state this was the standard of practice. There is ample information about the risks of early substance use in the developing brain and this is often translated over as a strong theoretical concern about use of BZDs although I am not aware of good data to support this concern. Combining adolescent drinking with BZD's and diversion are also real and large concerns but again not well quantified because the practice is so rare.

This is a big reason why the longitudinal data on stimulants showing reductions in SUD and substance use generally that have been repeatedly replicated were such a big deal. Had this not been the case and rates of substance abuse increased on kids taking long-term psychostimulants, I think it would be a pretty different landscape with their use.

I don't have a lot going for me, but at least I have never drunk alcohol. That's something I had not though of until you pointed out that pitfall that I can remind myself of. And that actually was a self-imposed rule, not even knowing about the particular interactions with benzos, but assuming—as a very anxious person—that alcohol would probably interact with any medicine. Oy. Sorry. I have a big birthday and have been jaywalking down memory lane more than usual of things that could have been and should have been different. I actually was on Adderall for 1-2 weeks my senior year of high school (was taken off Ativan for those two weeks as a trial). It made such a difference. I could stay in the classroom. The psychiatrist thought I improved too much, and I went back on the Ativan. I was never diagnosed correctly. The whole thing was a cluster****.

 

[whopper]

What types of implants?

Spinal implants for pain. Another "psychiatric clearance" for surgery I've gotten is for bariatric surgery.

Mentioned this before. I've seen other mental health professionals clear for surgery. I've asked them what is their criteria for clearance and more or less get a response of "well hey I get paid a few hundred dollars, so I just evaluate them and say they're cleared."

Some institutions such and higher level university hospitals have handled the above in this manner that is IMHO appropriate. The surgery team and the psychiatrist or psychologist have a meeting and came out with institution-only criteria and the case is thoroughly discussed.

This matter is something I find highly inappropriate. We cannot be asked to clear someone for something when there is no standard of care criteria to do so and the patient is then denied the benefits of that service possibly unfairly so. It's as if surgery has drafted us without knowing WTF they're doing.

Yes there's an emerging field of clearing patients for surgery based on psychological reasons but the standard is not yet made, not part of a educational curriculum nor professional societies have standardized them. Kind of like me telling a surgeon to fix someone's treatment resistant depression as if there's a device for it and when the surgeon asks me WTF I tell him, "hey there should be a device to implant you figure it out."

 

[SeniorWrangler]

In theory, the "clearance" is supposed to assess people for somatization, anxiety, depression, and "poor coping" but I have yet to see a standardized way of performing these evaluations and in practice it's just something they do to meet the requirements of insurance companies.

Here's a pretty good study showing that there's very little prognostic value in even detailed psychological testing before procedures:
North, R. B., Kidd, D. H., Wimberly, R. L., & Edwin, D. (1996). Prognostic value of psychological testing in patients undergoing spinal cord stimulation: a prospective study. Neurosurgery, 39(2), 301-311.

My cynical 2 cents is that spinal cord stimulators, like many pain procedures, are a very elaborate placebo, there's a case study of a patient getting complete pain relief after the treating surgeon forgot to turn the thing on before the patient went home.

 

[Liquid8]

Am hearing more about primary practitioners starting patients on CBD oil for anxiety, which is around $200 for a 30ml bottle!

Have had a few patients enquire about ketamine, but here it's mainly the pain specialists who are pushing this. Can recall a few local studies looking at it, but only finding temporary short term benefit.

Other trends are a big boost in transgender referrals, with most psychiatrists staying away and being quite cautious due to newly introduced bans against conversion therapy laws which seem to be quite vague. In essence, there's a feeling that if one is perceived as challenging the patient and not rubberstamping a diagnosis or clearing them for surgery they're liable to fall foul of said laws, although it does seem somewhat reactionary.

Of course, I'm following developments here, as we tend to follow the US in terms of treatment trends.

There was a psychiatrist round here drugging pts and staff with ketamine and then forcing himself sexually on them. Also doing home visits and having sex with a pts relative and prescribed her the abortion pill when she became pregnant….

Not bad. One local psychiatrist with a reputation for being a rude and aggressive jerk ended up getting de-registered by the medical board after one of his patients collapsed at an airport and was found with scripts he had written. Now that probably doesn't sound too bad in isolation, but 6 months prior he'd found himself in a very awkward position after he had referred one of this patients for a private hospital admission and a few days later demanded to be let into the nursing station wanting to change their drug chart and prescribe xanax , despite him not having any admitting rights and the patient being under the bedcard of another psychiatrist. Naturally the nurses on the ward refused, and it turned out that the patient and this psychiatrist were in a relationship. He of course denied this, claiming that he was her uncle... and then the hospital executives and her family got called in. Unbelievably he managed to evade sanctions at the time, but the later judgement findings revealed that he'd mislead the board on either the nature of their relationship or prescribing habits.